April 27, 2017

This article was compiled with the help of Dr. R.K.Mishra of Lucknow and Varun Dixit of Mumbai. Both of them are plastic surgeons. They have either published or presented work on this subject with the help of a sizable number of cases.

The slightly long title of this chapter points to the scope of the chapter. The literature reveals several classifications of this condition in which severe forms with more than 500 grams of tissue accompanied by marked ptosis of the breasts are included and are described as grade 4. The treatment of such cases might involve excision of skin and relocating as well as reducing the size of the nipple areola complex. That category is not included in the present chapter and will be covered in another chapter on reduction mammoplasty at a later date.

Mammary hyperplasia can occur immediately after birth in both the male as well as the female offspring because of high levels of maternal circulating estrogens. The condition lasts for as little as a few weeks and resolves spontaneously after the estrogen levels fall. In males, mammary hyperplasia also occurs when the level of circulating testosterone falls and this may occur any time after the age of fifty or even earlier. This condition is no different anatomically from the changes that occur in the adolescent except perhaps in the fact that the fat component of the lesion might be higher and is inevitably associated with skin laxity and excess. Gynecomastia can also be secondary to a variety of causes mainly hormonal dysfunction caused by abnormal secretions of various glands for example the pituitary, the thyroid, the adrenal, as well as the gonads and this might be a part of a syndrome. The condition is also caused by a variety of drugs, and the list is long. Generally speaking, though a physical examination reveals the non- hormonal non- syndromic nature of the condition, it might be prudent to get a basic hormonal assay done if there are signs and symptoms of feminization e.g. gynecoid body shape, absent or minimal facial hair, reduced or absent body hair, effeminate voice etc. and in specific cases even karyotyping to rule out Klinefelter’s syndrome before considering further treatment and a clearance in this regard from a relevant specialist would be ideal prior to surgery.

Pseudo-gynecomastia in which the male breast appears to be enlarged but in fact has little glandular enlargement is usually caused mainly by fatty tissue and might in turn be because of obesity. This is evident when the rest of the body is examined. Losing weight is advised in such cases. This is easier said than done and even if appropriate weight loss takes place its effect on and around the breast mound might not be such as to alter its size and shape adequately enough to allay the patient’s anxiety and this group of patients are also suitable candidates for surgery. In the last quarter of a century a virtual epidemic of morbid obesity seems to have broken out in the more affluent parts of the world. This is evident in India’s cities as well. All manner of specialists are devoted to treating this condition including bariatric surgeons who when they are successful, create a person who resembles an empty oversized bag of skin following what is called as RMWL (rapid massive weight loss). This person could be of either gender and often requires surgery in the area of the breast. That subject too is not covered in this chapter and will be covered later as the blog progresses.

The male breast remains rudimentary through-out life though on extremely rare occasions a male breast can grow not only like a female breast but can also lactate enough to feed a baby. The compiler of these short notes is reminded of a photograph from Bailey and Love’s short practise of surgery, a reliable textbook of the sixties of the last century in which a large man with multiple and enlarged breasts was feeding more than one infant There is no way to know if that individual in the photograph had some hormonal abnormality. The reason the male breast remains rudimentary lies in its structure which has very few ducts and several of them are in the form of solid cords which end blindly. The cords are devoid of lobules or alveoli which are the normal constituents of the glandular tissue in the female breast which are the receptor end organs for the pubertal proliferation induced by hormones. As mentioned earlier it is the transient imbalance or excess of estrogens or alteration in the ratio between the male and female hormones around the pubertal years in boys that causes the proliferation of the rudimentary glandular tissue which results in gynecomastia and at least in some cases this excess persists causing some psychological distress to the adolescent patient (!). Nowadays, a unique pattern of hormonal imbalance is commonly induced by improper and excessive use of steroid / supplements for the purpose of ‘body building’ leading to development of a gynecomastia. The Mechanism is as follows – the exogenously given testosterone supplement suppresses the endogenous secretion of testosterone. Not infrequently, once the exogenous testosterone is withdrawn the endogenous testosterone fails to normalize and results in a relative estrogen excess leading to gynecomastia. This type of gynecomastia can also cause some pain at the beginning. This pain may be persistent and may often be the main complaint and–such cases are usually found to be associated with dense or tough glandular tissue). It is now well documented that the incidence of malignancy in the male breast is not higher in patients (!) with gynecomastia. The indications for surgery usually therefore involve problems of ‘body image’ Not infrequently the severity of the psychological affection is not proportionate to the size of the lesion.

The concept of a ‘Body image’ has come to play a somewhat exaggerated role in the last few decades. When that idea is mixed up with gender identity the mixture can present a formidable problem and the surgeons should be somewhat wary when counselling such patients. The individuals might suffer teasing, are touched inappropriately, are reluctant to participate in body sports and also avoid changing rooms. Their morale may be low and some of them are on the verge of depression Expectations may be quite high and it is important to point out to the patient that removal of the excess tissue is not going to convert him into a male ‘hunk’ and upgrade his existing pectorals. The patient must be informed about the size of the actual glandular tissue that is felt on palpation and that the rest of the enlargement in and around the region of the breast is fatty in nature and if the patient is overweight it would be best for him to reduce weight so that the surgery can become more effective and easier. Generally speaking a more convex nipple areola complex is an indication of a glandular gynecomastia.

More often than not such is the state of the anxiety in the individual’s mind that this advice is rarely followed. Having said that, experientially in the eyes of the compiler of these short notes there might be a tendency in individuals with gynecomastia to have some abnormal proliferation of fat around the glandular enlargement but the literature is silent on whether this too is triggered by the hormonal influence. A modern lifestyle with accompanying caloric excesses also perhaps plays a part in this deposition of fat. Surprisingly few if any surgeons appear to use either an MRI or a CT scan to separately quantify the amount the glandular tissue and fat and seem to rely only on clinical examination.

The above narration leads to a discussion as to what a surgeon must do vis-a-vis a normalisation (!) of the area. Reconstruction would be perhaps a wrong word to use in these procedures. The first priority is to as far as possible reduce if not eliminate scarring because a conspicuous scar would be tantamount to letting the cat out of the bag. The curvilinear sub-mammary incision at some distance inferior to the areola is now history and is never employed. For some years now a curved incision at the junction of the areola and the normal skin extending from the nine-o-clock to the three-o-clock position was employed very frequently but its popularity has now receded because it was observed that the scars were more visible as compared to scars of an identical intra-areolar incision.

In either case the surgery had a “pin hole” or minimal access character in which extensive undermining of the skin was performed superficial to the lesion in its entirety and then the mass was lifted off the pectoral fascia and was excised in pieces after delivering it through the small incision. Surprisingly very large masses similar to a fairly developed female breast could be delivered through these incisions.

This method however had a major drawback with respect to the exact amount of fat which needed to be excised and frequently the post-operative appearance resembled a concave dish sitting on either side of the midline of the chest. The difficulty lay in the nature of the distribution of fat which either clung to the mammary tissue or was distributed unevenly around the hypertrophied breast tissue.

The technique of liposuction in vogue for the last quarter of a century has been a great boon in the surgery for gynecomastia because not only can fat be removed separately from the gland by this technique but as it is being removed the surgeon can inspect the contour of the chest wall intermittently. What is more relevant is that, this removal by liposuction can be performed prior to the excision of the fibro-glandular tissue which then becomes much easier to perform.

Here too because the normal male areola and nipple has a somewhat convex appearance it is easier to leave behind a proper amount of glandular tissue (the disc) behind, in front of the backdrop of a chest which is now bereft of excess abnormal fat. Several surgeons now take recourse to an incision across the areola from the nine o clock to the three o clock position and also transect the nipple. The incision is then deepened circumventing the ‘disc tissue’ to be left behind and then excising the rest of the gland.

To facilitate this excision a cruciate incision can also be employed which includes the nipple as well resulting in four triangular flaps with their bases towards the periphery of the areola. All these incisions can be closed in one layer with fine sutures and several surgeons opt for the absorbable variety. Dr R.K. Mishra who has contributed to this chapter and whose case reports are reproduced at the end of the chapter performs the glandular excision and extraction by way of a surgical opening only on the top of the nipple.

The endpoint of surgery is a well contoured chest wall anteriorly as well as laterally. In fact, a small concavity is evident subjacent to the areola immediately after surgery. This depression always fills up during the healing process by 4 to 6 weeks after surgery. A customised compressive garment is applied immediately after surgery. This must be worn 24/7 for 4 to 6 weeks after surgery.

Generally, it is now accepted that surgery should be undertaken only a year after the lesion appears because the lesion(!) might reduce as hormonal imbalance wanes and also because the patient might be able to adjust to his condition if the swelling does not increase. Ideally it is advisable to perform the procedure between the age of 18-21 years In some cases surgery may be performed earlier if the boys are significantly affected in their minds. However, in such cases the parents must be explained about the possibility of recurrence during the subsequent years of growth. Surgery in older grown-up males up to the age of forty is also now being performed for purely aesthetic reasons and here the selection of cases is easier because the subjects are more mature.

The condition is almost always bilateral and frequently the two sides are neither equal nor symmetrical. Smaller lesions are amenable to surgery under local anaesthesia but the larger ones are not and it is best to impress on the patients that though the incisions are small, in effect a bilateral mastectomy is being performed, leading to a large enclosed dead space and that post-operative reactionary bleeding is possible and to prevent that possibility a tight pressure dressing or garment will be given post operatively. This garment serves several purposes – minimises post-operative swelling / edema, helps to prevent a seroma and facilitates better skin co-option. The surgeon also needs to be extra careful during this type of ‘key’ hole surgery and must ensure an absolute dry bed prior to closure. In the past two decades, the economy of scale has been such that more and more surgeries are being performed on an out-patient ‘day-care’ basis and there is a tendency to discharge the patient early but it must be remembered that liposuction involving large quantities of fat has its own consequences including hypovolemia and electrolyte imbalance and monitoring of the pulse rate as well as blood pressure should be done over several hours prior to discharge though this is rare as the volume of the lipoaspirate is not very large; never more than 8% of body weight. Electrolyte imbalance often manifests as a change in the sensorium and any unusual pain is usually a tell-tale sign of bleeding with formation of hematoma and this can be diagnosed only by removing the dressing. There should be no sense of shame in re-exploring the wound and should a hematoma be observed the wound should be re-explored, the hematoma evacuated and haemostasis achieved because otherwise the blood clot might increase over a period of time and even if it does not, it might evolve into a seroma which may take a long time to absorb, will need repeated aspirations, ultimately marring the result in that area. Fat embolism is another dreaded problem of any liposuction procedure. This may manifest in small volume liposuctions as well especially when increased bleeding is encountered during the early stages of the procedure. The patient must also be informed that the pressure dressing will ultimately be replaced by a tight-fitting pressure garment over the chest to help the skin to snugly drape over the recently created surgical hollow. If the cavities created following surgery (the pressure garment and/or dressing not-withstanding) should have a drain through the liposuction site is a matter of individual choice as well as how the case progressed on the table. Dr. R.K. Mishra the senior of the two contributors leaves the liposuction incision open and covers it with a bulky absorbent dressing.

A series of photographs are reproduced below showing the surgical technique as well as some results. In the cases operated by Dr. R.K. Mishra the glandular excision and extraction has been performed by way of an incision on top of the nipple as mentioned in the text. A representative sample of his technique as well as cases are given first followed by cases operated by Varun Dixit who is inclined to use the cruciate incision earlier described in the text

The following pictures are contributed by Dr. R.K. Mishra with his technique in which the top of the nipple is deroofed to approach the mammary gland after liposuction.

The following pictures are contributed by Varun Dixit who is inclined to use the cruciate incision across the areola (the incision is barely 1-2 mm beyond the nipple in all directions and never across the entire areola).